Note Examples
Example SOAP

Example SOAP

SUBJECTIVE
Presentation:

  • Chief Complaint: Client, a 11 year old female, presented for her fifth therapy session. Continues to endorse anxiety symptoms including worry, difficulty sleeping, and avoidance behaviors.
    • Quote (Chief Complaint): “I’m still worried about a lot of things and having trouble sleeping most nights."
  • Impairments And Challenges: Client reports anxiety continues to impair concentration at school, academic performance has not improved. Anxiety prevents participation in social activities and sleepovers. Ongoing irritability and low frustration tolerance due to lack of sleep noted.
    • Quote (Impairments And Challenges): “ It's so hard to focus on schoolwork when I'm worried. I don't want to hang out with friends because I just want to go home."

Psychological Factors:

  • Symptom 1:
    • Symptom Description: Excessive general anxiety, uncontrollable worry, rumination
    • Onset: 6 months ago
    • Frequency: Daily
    • Ascendance: Minimal improvement in worry
    • Intensity: Severe
    • Duration: Persistent, 6 months
    • Quote (Symptom): “I can't stop worrying all the time no matter what I try."
  • Symptom 2:
    • Symptom Description: Insomnia, difficulty falling asleep and staying asleep most night.
    • Onset: 6 months ago
    • Frequency: 5-6 nights per week
    • Ascendance: No improvement in sleep difficulties reported
    • Intensity: Moderate
    • Duration: Persistent, 6 months
    • Quote (Symptom): “ I toss and turn for hours before I can fall asleep and then I'm tired all day."

OBJECTIVE
Clinical Assessment:

  • Assessment Tool: Clinical Interview
  • Results: Client continues to report severe anxiety and worry across settings. Sleep remains disturbed most nights. Avoidance behaviors limit social activities. Psychoeducation and early CBT skills have resulted in minimal symptom reduction to date.
  • Status: Will administer SCARED assessment for anxiety at next session for further evaluation.

Risk Assessment:

  • Risks Or Safety Concerns: No risks or safety concerns noted during session. Client denies suicidal ideation or self harm. No homicidal ideation evident.

Interventions:

  • Therapeutic Approach Or Modality: CBT interventions focused on identifying and challenging anxious automatic thoughts.
  • Psychological Interventions:
    -Assigned thought records for homework.
    -Modeled modifying anxious thoughts through Socratic questioning.
    -Practiced cognitive restructuring skill during session.
  • Rationale: Cognitive restructuring aimed at teaching client to identify and replace anxious thinking patterns with more balanced thoughts.

ASSESSMENT
Progress And Response:

  • Response To Treatment: Client has been engaged in therapy process but still struggles with consistent application of CBT skills outside of sessions. Minimal reduction in target symptoms to date.
  • Specific Examples Or Instances: Completed thought records inconsistently since last session. Participated willingly in cognitive restructuring exercise during session but had difficulty generating alternative thoughts independently.
  • Quote (Progress): “ I’m trying to use the thought records, but it's hard to remember. I still feel worried all the time."
  • Challenges To Progress: Client struggles with utilizing CBT skills consistently outside of therapy sessions. Continued anxiety symptoms interfere with concentration needed to implement CBT techniques.
  • Therapist Observations And Reflections: Client has grasped CBT concepts but minimal progress may signify need to adjust therapeutic approach to better meet client's needs. Will consult with parents for additional insight into symptoms and functioning at home and school.
  • Therapeutic Alliance: Client was engaged in session with good rapport. No ruptures in therapeutic relationship noted.

PLAN
Follow Up Actions And Plans:

  • Homework: Complete daily thought records. Challenge anxious thoughts using skills practiced in session.
  • Plan For Future Session: Administer SCARED assessment of anxiety. Adjust CBT approach as needed. Increase parental involvement.
  • Plans For Continued Treatment: Continue weekly 50-minute CBT sessions.
  • Coordination Of Care: Parent reports speaking regularly with pediatrician who made referral. Will consult with pediatrician and parents for additional recommendations to enhance progress.